Alarming rise in HIV cases in Pakistan: Challenges and future recommendations at hand

Abstract Background Human immunodeficiency virus (HIV) is a retrovirus that suppresses the immune system by reducing the CD4+ T lymphocytes level. It has become a global challenge with fast prevalence ratio. Like other developing countries, Pakistan is also struggling for overcoming this viral disease since very first reported case in 1987. Aim To update the society on the alarming rise in HIV cases in Pakistan: challenges and future recommendations at hand. Materials and Methods The review paper utilized different search engines such pubmed central, scopus, web of science, google scholar etc. to conduct this review paper. Results Lack of awareness, low literacy rate, practice of unhygienic equipment in healthcare departments, unstable economy, and unsafe sexual practices are the major factors behind the increasing rate of AIDS in Pakistan. Conclusion By regulating healthcare practices and policies, promoting psychological counseling to HIV positive patients, educating the society and minimizing commercial sex practices, Pakistan can overcome this viral disease.


| INTRODUCTION
From the last 40 years, human immunodeficiency virus (HIV) has become a global issue. The researchers studied the pathology of HIV including its etiology, pathogenesis, morphological changes and biochemistry to overcome the immunosuppression caused by it. 1 HIV (member of Lentivirus genus), 2 has two types HIV-1 and HIV-2.
HIV-1 and HIV-2 have the same basic structures, like presence of three structural genes gag, pol and env, but they both vary in organization of their genome. 3 Both types of HIV infect the immune system cells and alter the immune response. This effect spreads to the regional lymph node and blood stream. 4 Primary targets for HIV are CD4+ immune cells. The HIV-1 variant is the most dominant and when it progresses to its advanced stage, it leads to the development of Acquired Immunodeficiency Syndrome. 5 Injectable drugs, unsafe blood transfusion, commercial sex and men sex with men and transgenders are the basic sources for the virus spreading. 6 We can define AIDS as an advanced level of HIV in which CD4+ cells are lesser than 200 per cubic millimeter. Aids results in various infections, cancers and tumors as it is an immunosuppression phenomenon. 7 According to the Factsheet published by UNAIDS, the number of affected people has increased up to 38.4 million in 2021 out of which 1.5 million were newly affected in 2021. 8 HIV is one of the leading causes for mortality worldwide. 9 Like other viruses, HIV attaches to its target cell i.e. CH4+ lymphocytes and injects its RNA into host cell after penetration. RNA is converted into DNA in a process called as reverse transcription.  Figure 1. 10 A few first aid procedures should be followed while dealing with someone who is suspected of having AIDS. The most crucial action is to get help right away from a trained healthcare expert. Maintaining composure and reassuring the person while waiting for assistance is crucial. You should also control any bleeding, protect yourself by donning gloves and a face mask, avoid sharing personal items that might be contaminated with blood or other bodily fluids, and show support to anyone who may be feeling alone and isolated. When dealing with someone who may have AIDS, getting medical help as soon as you can is essential. 11 Drugs for treatment of HIV are also formulated on this life cycle. Drugs inhibit the activity of these 3 enzymes i.e. reverse transcriptase, integrase and protease. 10

| CURRENT STATUS IN PAKISTAN
In 1987, Pakistan came across its very first HIV case which was caused because of unsafe blood transfusion. 12 In comparison to its neighbors, Pakistan has experienced comparatively few locally centers which is 61% of registered HIV cases. 18

| CHALLENGES OF HUMAN IMMUNODEFICIENCY VIRUS
The low literacy rate of Pakistan results in the increasing rate of transmission and haphazardly spreading of HIV because people don't understand the precautionary steps and measures taken by health reforming institutions due to their illiteracy. 19 Homosexual intercourse, extramarital relationships, unsafe blood transfusion and usage of contaminated syringes result in spreading of HIV. 20 Concealing F I G U R E 1 Life cycle of HIV virus. 10 HIV, human immunodeficiency virus.
HIV of an infected person due to the fear of community prejudicing also results in spreading of HIV. 21 The unsafe and unlawful sex in prostitution also results in transmission of HIV. 22 A total of 5.5% HIV prevalence was estimated in the transgender community of Pakistan in 2020. 23 Healthcare workers are also exposed to the infection due to the lack of guidelines and proper safety equipment. 24 Poor literacy rates, widespread poverty, and hazardous blood transfusions made Pakistan more assailable to HIV. 25 The medical professionals and students have major gap in their knowledge and practices. 26 Due to societal embarrassment and the burden of admitting the reality of extramarital sexual behavior, which embarrasses them in front of their families and even doctors, patients occasionally are reluctant to disclose symptoms at clinics. The growing number of new HIV patients, coupled with the lengthy travel durations to receive medical attention, substantially restrict the accessibility and adherence of ART. 27 Because HIV is a virus that mutates quickly, developing a vaccine to protect against all HIV mutations is a huge issue. 28  and 36%, respectively. 30 It may be note that homosexuals are marking up 5.2% of Pakistan's overall population which is a major contributor to the spread of AIDS. As a result, there are now approximately 85,000 additional AIDS patients in the homosexual community. 21 Less than 1% of the general population in Pakistan has been estimated to have HIV, which suggests the epidemic is in its concentrated phase.
However, the main high-risk groups are injectable drug users, repatriated migrant laborers, and sex workers. 33 Diseases like HIV have marginally higher impact in a country facing economic issues, low literacy rate and where people believe in myths and misconceptions instead of proper health protocols. 34

| CHALLENGES OF HUMAN IMMUNODEFICIENCY VIRUS INFECTIONS FACED BY PATIENTS AND SOCIETY IN PAKISTAN
Regardless of whether it appears ridiculous, the affected must first accept the situation before they can successfully overcome it. 6  are still many prohibitions and stereotypes around HIV. Especially in rural areas, HIV is viewed as terribly unpleasant. Even talking about this issue is prohibited. 35 There is very little general knowledge of HIV/AIDS. A study of instructors at schools in the nation's capital, Islamabad, revealed the seriousness of the crisis. A remarkable 60% of the instructors who replied said they believed that HIV was unrelated to our cultural context. 6 People with medical disorders also suffer from mental health issues like anxiety, depression etc. 36 Today, more than 350 million individuals worldwide suffer from depression. Depression has a lifetime prevalence of around 3%-17% and is the fourth most common disability globally. 37 According to recent estimates, roughly 121 million HIV/AIDSinfected people worldwide suffer from depression. 38  When compared to other parts of Pakistan, Punjab province has higher HIV prevalence due to a number of causes. One cause could be Punjab's increased population density and urbanization, which could increase the virus's ability to spread. In Punjab, cultural and societal traditions may also make it more challenging to openly discuss and handle HIV-related concerns, which might increase stigma and prejudice against those who are HIV-positive. 33 In some parts of Punjab, particularly in rural or distant locations, access to healthcare and preventative services may also be restricted. A greater risk of HIV transmission may be caused by the lack of access to preventative services such condoms, clean syringes for drug users, HIV testing, and counseling. 40 Many health problems that people with AIDS frequently deal with can have an impact on their general wellbeing. Due to their compromised immune systems, they are more prone to opportunistic infections like pneumonia, tuberculosis, and some cancers. HIV may also affect the brain and nerve system, which can result in neurological conditions including dementia, neuropathy, and seizures. Cardiovascular illness, as well as mental health conditions including depression, anxiety, and drug addiction, are possible health problems for persons with AIDS.
In addition, there may be problems with sex desire, vaginal dryness, and erectile dysfunction. AIDS patients often have nutritional deficits, skin concerns, gastrointestinal problems, and oral health problems. A multidisciplinary strategy combining healthcare experts, mental health specialists, and other support services is often necessary for the proper treatment of various health problems. Antiretroviral therapy (ART), drugs to treat opportunistic infections, and counseling and assistance to treat mental health difficulties are all possible forms of treatment.
People with AIDS may enhance their quality of life and better manage their illness by addressing these health concerns. 41,42 Homosexuality is seen as a sin and is prohibited in the Islamic religion

ACKNOWLEDGMENTS
We thank the anonymous referees for their useful suggestions.

CONFLICT OF INTEREST STATEMENT
The authors declare no conflicts of interest.

DATA AVAILABILITY STATEMENT
No data was used for the research described in the article.

ETHICS STATEMENT
There are no human participants in this article and informed consent is not applicable.

TRANSPARENCY STATEMENT
The lead author Emmanuel Ifeanyi Obeagu affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.